A successful complete resection for multidrug-resistant giant gastrointestinal stromal tumor invading the transverse colon with multiple liver metastases in a young female: a case report.

BACKGROUND: Gastrointestinal stromal tumors (GISTs) are rare in young people and are often detected after becoming symptomatic or at an advanced stage. Herein, we report a case of complete reduction surgery for a substantially large malignant gastric GIST with multiple liver metastases in a young woman who successfully resulted in R0 surgery. CASE PRESENTATION: An 18-year-old woman presented to our hospital with anorexia and vomiting, and was diagnosed with a 17 cm gastric GIST with transverse colon invasion and multiple liver metastases. Due to being considered unresectable, tyrosine and multi-kinase inhibitor therapy were administered up to the fourth line yielding no response. After careful discussion at a multidisciplinary team conference, pancreatoduodenectomy or distal gastrectomy, transverse colectomy, and resection of the liver metastases were planned. Consequently, distal gastrectomy, transverse colectomy, resection of the liver metastases, and incidental peritoneal metastases were performed. Although the primary goal of the surgery was to reduce the volume of the tumor as much as possible, the results revealed that the complete removal of all detectable tumors was achieved. No recurrence was observed after surgery for 27 months with long-term adjuvant imatinib therapy. CONCLUSIONS: Even for highly advanced GISTs, aggressive surgery followed by adjuvant drug therapy may prolong survival in young patients.

Clinical Effectiveness of Preoperative 18F-FDG PET/CT in Predicting Pathological Tumor Grade in Patients with Pseudomyxoma Peritonei Originating from Appendix: A Retrospective Cohort Study.

BACKGROUND: Cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy is the standard treatment for patients with pseudomyxoma peritonei (PMP). In some malignancies, the standard uptake value of positron emission tomography with 2-deoxy-2-18F-fluoro-D-glucose integrated with computed tomography (18F-FDG PET/CT) is now accepted as a reliable indicator of neoplastic behavior. This study aimed to evaluate the association between the maximum standardized uptake value (SUVmax) and pathological grade in patients with PMP and to investigate the significance of SUVmax in the preoperative assessment of these patients. PATIENTS AND METHODS: In this retrospective single-center study, consecutively enrolled patients diagnosed with PMP of appendiceal origin underwent preoperative 18F-FDG PET/CT. SUVmax was calculated as the highest SUVmax value in the abdomen excluding the primary site. SUVmax was compared with the pathological grade (low or high grade) of PMP tumors according to the World Health Organization classification and further analyzed with respect to the estimated cutoff point, sensitivity, specificity, and receiver operating characteristic. RESULTS: In total, 160 patients were included. CRS was successfully performed in 93 patients and palliative debulking surgery in 67 patients. The pathological grade was high in 45 patients and low in 115. High-grade patients had a higher median SUVmax on 18F-FDG PET/CT than did low-grade patients (3.83 versus 2.34, p < 0.001). The highest area under the curve was 0.81, with a sensitivity of 77.8%, specificity of 72.3%, and cutoff point of 2.63. CONCLUSION: This study suggests that the SUVmax of preoperative 18F-FDG PET/CT is associated with the pathological grade in patients with PMP.

Usefulness of indocyanine green fluorescence-guided small intestinal bleeding site identification in small bowel resection: a report of two cases and literature review.

Small bowel bleeding that does not respond to conservative therapy requires surgical resection. However, identifying the bleeding sites intraoperatively is challenging. Indocyanine green (ICG) fluorescence imaging improves diagnosis of small bowel bleeding and surgical decision-making by visualizing blood flow. Herein, we reported two cases of small bowel bleeding that were successfully treated by using ICG to identify the bleeding sites and determine the extent of small bowel resection. The patients were a 46-year-old and a 75-year-old woman, both of whom presented with melena. Contrast-enhanced computed tomography and arteriography confirmed small bowel bleeding, and rebleeding occurred in both patients after transcatheter arterial embolization. Emergent surgeries were performed, and intraoperative selective angiography with ICG injections was conducted to identify obscure bleeding sites. ICG fluorescence identified all bleeding sites in both cases, and small bowel resections were successfully performed. The postoperative courses were uneventful, and both patients had a favorable postoperative course without recurrence of bleeding. ICG fluorescence imaging can safely identify the sites of intestinal bleeding and determine the appropriate extent of bowel resection.

Endovascular embolization and needle aspiration of a life-threatening cervical hematoma due to a neurofibromatosis type 1-associated arteriovenous fistula: illustrative case.

BACKGROUND: In cases of neurofibromatosis in which the bleeding source is considered strongly related to a neurofibroma, an open surgical approach could risk uncontrollable bleeding from the vascular wall infiltration by neurofibroma. The case of a neurofibromatosis type 1 (NF1)-associated arteriovenous fistula presenting with a life-threatening cervical hematoma that was successfully treated with alternative treatment is described. OBSERVATIONS: A 68-year-old woman diagnosed with NF1 presented with sudden onset of a spontaneous right cervical mass. Neck imaging on admission showed a massive subcutaneous hematoma with tracheal deviation and abnormal vascular structure in the hematoma. Digital subtraction angiography showed that an arteriovenous fistula (AVF) fed from a vertebral artery located within the hematoma cavity was the primary source of bleeding and feeding arteries from the occipital artery to the neurofibroma. Embolization of the cervical neurofibroma, as well as the AVF, was performed to reduce the secondary risk of bleeding, and was accomplished. After endovascular treatment, needle aspiration of the cervical hematoma was performed to reduce the mass effect. LESSONS: When performing open surgery via tissues with neurofibromatosis proliferation, uncontrollable bleeding can occur. Therefore, endovascular embolization and needle aspiration of the hematoma should be considered in this setting.

Outcomes following cholecystectomy in human immunodeficiency virus-positive patients treated with antiretroviral therapy: A retrospective cohort study.

The number of the human immunodeficiency virus (HIV)-positive patients are increasing worldwide, and more HIV-positive patients are undergoing urgent or elective cholecystectomy. There is still insufficient evidence on the relationship between surgical complications of cholecystectomy and antiviral status in HIV-positive patients. The purpose of the present study is to evaluate surgical outcomes after cholecystectomy in HIV-positive patients. Records of consecutive HIV-positive patients who underwent cholecystectomy between January 2010 and December 2020 were reviewed retrospectively. Patients were divided into urgent and elective surgery groups. Urgent surgery was defined as surgery within 48 hours of admission. Postoperative complications were evaluated according to the Clavien-Dindo classification. A total of 30 HIV-positive patients underwent urgent (n = 7) or elective (n = 23) cholecystectomy. Four complications (13.3%) occurred, and the rate was significantly higher in the urgent group than in the elective group (p = 0.008). However, all complications were minor (3 cases of grade I and one case of grade II), and there were no severe postoperative complications. There was no significant difference in CD4+ lymphocyte status in all patients and between the 2 groups before and after surgery (p = 0.133). No cases of postoperative deterioration in the control of HIV infection were observed. In conclusion, cholecystectomy in HIV-positive patients with controlled HIV under recent antiretroviral therapy may be performed safely even in an emergency situation.

Dysregulated metabolism and behaviors by disrupting gut microbiota in prenatal and neonatal mice.

The live microbiota ecosystem in the intestine plays a critical role in maintaining the normal physiological and psychological functions in both animals and human beings. However, the chronic effect of microbiota disturbances during prenatal and neonatal developing periods on animal's health remains less studied. In the current study, pregnant ICR mice were fed with an antibiotic diet (7-g nebacitin [bacitracin-neomycin sulphate 2:1]/kg standard diet) from day 14 of conception, and their offspring were provided with the same diet till the termination of the experiments. Dams treated with antibiotics showed increased body weight along with enlarged gut. Antibiotic-treated offspring revealed decreased bodyweight, increased food, water, and sucrose intake. Administration of antibiotics affected corticosterone responsivity to acute 20 min restraint challenge in male pups. In behavior tests, female pups showed decreased movement in open field while male pups revealed decreased latency to open arms in elevated plus maze test and immobility time in tail suspension test. Together, these results suggested that early antibiotic exposure may impact on the food intake, body weight gain, and emotional behavior regulation in mice.

Transverse colon invasion from intrahepatic cholangiocarcinoma with lymph node metastasis in the regional mesocolon: a case report.

BACKGROUND: Intrahepatic cholangiocarcinoma (ICC) is an aggressive cancer with high frequency of extrahepatic metastasis at diagnosis. However, there have been very few reports of direct invasion to transverse mesocolon with lymph node metastasis in the regional mesocolon. CASE PRESENTATION: A 71-year-old man presented to our hospital with anorexia and weight loss. Abdominal computed tomography (CT) revealed enlarged gallbladder wall with intrahepatic tumor extended from the gallbladder. The transverse colon was located adjacent to the gallbladder and its wall was thickened, indicating tumor invasion. Some enlarged lymph nodes were observed in the transverse mesocolon, suggesting metastatic or inflammatory lymph node swelling. Percutaneous liver biopsy detected poorly differentiated adenocarcinoma. After confirming the absence of remote metastasis and peritoneal dissemination, surgical resection including right hepatectomy and right hemicolectomy was performed. The pathological diagnosis was adenosquamous carcinoma of the liver and lymph node metastasis in the transverse mesocolon. The surgical margins were negative and R0 resection was achieved. Although adjuvant chemotherapy was administered, follow-up CT detected multiple metastases to the lung 4 months after surgery. The patient died 12 months after the operation. CONCLUSIONS: Direct colon invasion from ICC may cause lymph node metastasis in the regional mesocolon. Careful assessment is necessary for the diagnosis of enlarged lymph nodes in ICC with direct colon invasion.

A case of paroxysmal homonymous hemianopsia: Uncommon presentation of nonconvulsive status epilepticus.

Paroxysmal homonymous hemianopsia (HH) is uncommon presentation of epilepsy. We demonstrate a rare case of paroxysmal HH that was diagnosed by magnetic resonance (MR) arterial spin-labeling (ASL). A 82-year-old woman presented with abrupt onset of isolated visual field abnormality without convulsive epilepsy at 16 days after a traumatic head injury. Diffusion weighted and MR-ASL obtained on admission revealed hyperintensity and hyperperfusion in the right temporo-occipital cortex. Nonconvulsive status epilepticus was suspected. The patient was treated with oral levetiracetam and the symptoms resolved in 3 days. Paroxysmal HH should be considered in patients who present with simple partial epilepsy, and MR-ASL imaging may assist in the differential diagnosis of these patients.

Orally administrated D-arginine exhibits higher enrichment in the brain and milk than L-arginine in ICR mice.

D-Amino acids exert various physiological functions and are widely present in animals. However, they are absorbed to a lesser extent than L-amino acids. Little is known about D-arginine (D-Arg); however, its isomer L-Arg serves as a substrate for several metabolites and exhibits various functions including promotion of growth hormone secretion. Milk is the only nutrient source for infants; it plays an important role during their initial growth and brain development. No studies have evaluated the availability of D-Arg in the brain and milk in mammals. Here, we have studied the differential availability of orally administered D- and L-Arg in the brain and milk using ICR mice. Our results revealed that without D-Arg administration, D-Arg was undetectable in both plasma and brain samples. However, the plasma D-Arg was about twice the concentration of L-Arg post administration of the same. In the cerebral cortex and hypothalamus, L-Arg concentration remained almost constant for over period of 90 min after L-Arg treatment. Nevertheless, the L-Arg concentration decreased after D-Arg administration with time compared to the case post L-Arg administration. Contrastingly, D-Arg level sharply increased at both the brain regions with time after D-Arg treatment. Furthermore, L-Arg concentration in the milk hardly increased after L-Arg administration. Interestingly, oral administration of D-Arg showed efficient enrichment of D-Arg in milk, compared with L-Arg. Thus, our results imply that D-Arg may be available for brain development and infant nourishment through milk as an oral drug and/or nutrient supplement.

A case of chronic subdural hematoma demonstrating the epileptic focus at the area with sulcal hyperintensity on fluid-attenuated inversion recovery image.

Although the sulcal hyperintensity on fluid-attenuated inversion recovery (FLAIR) images is detected in some chronic subdural hematoma (CSDH) cases, its clinical significance remains determined. A 77-year-old man with symptomatic CSDH presented with generalized tonic-clonic seizures at 9 days after surgery. 123I-iomazenil -single photon emission computed tomography revealed transient reduction in cortical benzodiazepine receptors binding potential at the region corresponding to that of the sulcal hyperintensity on FLAIR images. Findings of sulcal hyperintensity on FLAIR imaging under the CSDH may have a relation with the cause of epileptic seizure.

A Case of Cisternal Pilocytic Astrocytoma Diagnosed with the Balanced Steady-State Free Precession Sequence for Magnetic Resonance Imaging: A Rare Cause of Subarachnoid Hemorrhage.

OBJECTIVES: In approximately 15% of cases of spontaneous subarachnoid hemorrhage (SAH), an obvious source of bleeding cannot be identified by angiography; these are considered cases of SAH of unknown etiology. A rare case of cisternal pilocytic astrocytoma (PA) presenting with SAH is reported. The usefulness of the balanced steady-state free precession (bSSFP) sequence for magnetic resonance imaging (MRI) to detect small cisternal lesions is discussed. CASE DESCRIPTION: The case of a 73-year-old woman who developed repeated SAHs owing to a cisternal PA is presented. She experienced sudden onset of headache and vomiting, and brain computed tomography showed diffuse SAH, whereas angiography demonstrated normal vasculature. Follow-up imaging, including T1-weighted, T2-weighted, T1-weighted contrast-enhanced, and diffusion-weighted MRI, did not show any parenchymal or cisternal lesions, although computed tomography and fluid-attenuated inversion recovery MRI showed SAH in the same region. In contrast, the bSSFP sequence, taken as a different sequence on the same day, showed mixed-intensity reticular lesions in the left basal cistern, while neither hematoma nor positive findings were identified with the other sequences. Based on the radiologic finding and the repeated history of SAH, the lesions were partially removed 2 weeks after onset. Histological examination showed a PA. CONCLUSIONS: Despite being extremely rare, a small cisternal lesion should be considered as a cause of SAH of unknown etiology. The bSSFP sequence may be useful for detecting cisternal lesions that may be missed on the routine MRI sequences.

Microsurgical Management for Aneurysm Arising from a Low-Lying Internal Carotid Artery-Posterior Communicating Artery Bifurcation through the Anterior Temporal Approach.

A low-lying internal carotid artery (ICA) running closer to the skull base than in usual cases prevents use of the standard transsylvian approach (TSA) to view an aneurysm through the retrocarotid space. A 75-year-old male had a 10-day history of headache and left eyelid ptosis. Initial computed tomography (CT) showed no evidence of subarachnoid hemorrhage. Emergency three-dimensional CT angiography showed a saccular aneurysm with bleb arising from the left horizontally projecting ICA. The aneurysm was approached through the TSA but could not be visualized well. We used the anterior temporal approach (ATA) followed by the TSA, offering a more lateral line of vision and allowing the surgeon to visualize the aneurysmal neck. The aneurysm was successfully obliterated. The ATA provided a better lateral view than the standard TSA for the ICA aneurysm. We emphasize the effectiveness of ATA for aneurysm arising from a low-lying IC-posterior communicating artery bifurcation.

Decreased stress-induced depression-like behavior in lactating rats is associated with changes in the hypothalamic-pituitary-adrenal axis, brain monoamines, and brain amino acid metabolism.

Depression-like behavior during lactation may relate to changes in the hypothalamic-pituitary-adrenal (HPA) axis, brain monoamines, and brain amino acid metabolism. This study investigated how the behavior, HPA axis activity, brain monoamines, and brain free amino acid metabolism of rats were changed by stress or lactation period. Rats were separated into four groups: (1) control lactating (n = 6), (2) stress lactating (n = 6), (3) control virgin (n = 7), and (4) stress virgin (n = 7) and restrained for 30 min a total of ten times (once every other day) from postnatal day (PND) 1. Depression-like behavior in the forced swimming test (FST) on PND 10 and concentration of corticosterone in plasma, as well as monoamines and L-amino acids including ß-alanine, γ-aminobutyric acid, cystathionine, 3-methyl-histidine and taurine in the prefrontal cortex and hypothalamus on PND 19 were measured. The plasma corticosterone concentration, measured just after restraint stress, was significantly higher in the stress groups, versus the control groups, but there were no significant differences between control and stress lactating groups. Depression-like behavior (immobility) in the FST was significantly lower in the lactating groups, versus the virgin groups. Stress enhanced dopamine and glutamate, and decreased threonine and glycine concentrations in the hypothalamus. In addition, 3-methoxy-4-hydroxyphenylglycol (MHPG), threonine and ornithine concentrations in the prefrontal cortex were significantly higher in the lactating groups compared with the virgin groups. Changes in plasma corticosterone concentration, monoamine, and amino acid metabolism may relate to stress-induced depression-like behavior in lactating rats. Lay summary This study revealed that reduced depression-like behavior in lactating, relative to virgin rats, was associated with changes in monoamine and amino acid metabolism in the prefrontal cortex of the brain. In addition, the effect of stress on monoamine and amino acid metabolism is prominently observed in the hypothalamus and may be related to neuroendocrine stress axis activity and secretion of corticosterone. This study suggested that stress-induced depression-like behavior may be associated with several changes in the stress axis, brain monoamines, and brain amino acid metabolism. These parameters were associated with attenuated depression-like behavior in lactating rats.

Impact of the Intracranial Course of Internal Carotid Artery on Optimal Surgical Approach for Posterior Communicating Artery Aneurysms.

BACKGROUND: The anterior temporal approach (ATA) has been reported as suitable for surgical clipping of posteriorly projecting internal carotid artery (ICA) aneurysms. As the ICA follows a variable course, tortuosity of the ICA may affect visualization of the aneurysm. The aim of this study was to investigate the impact of the intracranial course of the ICA and aneurysm projection on surgical approach. METHODS: Consecutive patients with posterior communicating artery aneurysms treated with clipping at our hospital between May 2015 and April 2018 were retrospectively reviewed. When the transsylvian approach (TSA) could not achieve adequate exposure of the aneurysm, the ATA was subsequently performed. Distance between the ICA and the anterior and posterior clinoid line, angle between the midline and the C1 segment of the ICA, and aneurysm projection were compared between ATA and TSA groups. RESULTS: Of 52 patients (40 ruptured, 12 unruptured), 12 were in the ATA group, and 40 were in the TSA group. Mean ICA-anterior and posterior clinoid distance was significantly shorter in the ATA group than in the TSA group (P = 0.002), and mean midline-C1 angle was significantly larger in the ATA group than in the TSA group (P < 0.0001). The ATA group was associated with a greater frequency of posteriorly projecting aneurysms (12 of 12; 100%) than the TSA group (9 of 40; 22.5%) (P < 0.00001). CONCLUSIONS: A low-lying, laterally projecting intracranial ICA and posteriorly projecting aneurysm are predictors of the necessity for the ATA in the surgical clipping of posterior communicating artery aneurysms.

Fenestrated Mini-Clip Application to Preserve a Tightly Adhering Branch Artery to a Middle Cerebral Artery Aneurysm: Technical Case Report.

BACKGROUND: Fenestrated mini-clips have been reported as useful for treating dog ear-shaped remnant aneurysms, the small aneurysms to which the efferent artery adheres or is impeded by the surrounding neurovascular structure in the restricted operative corridor, because of the smaller clip head. Here, the alternative utility of fenestrated mini-clip was reported by mentioning the narrower clip blade. METHODS: We report a case of middle cerebral artery aneurysm tightly adhered by the anterior temporal artery (ATA) as well as the efferent arteries and demonstrate the utility of fenestrated mini-clip. RESULTS: During aneurysm dissection, the superior division of the M2 segment of the middle cerebral artery and the ATA adhered tightly to the aneurysm, thereby restricting meticulous aneurysm dissection. To preserve the efferent artery and the ATA, a fenestrated standard clip was applied, transmitting the efferent artery, and the clip blade was applied in the restricted space between the adhering ATA and the aneurysm neck. However, because kinking of the ATA was observed following first clip application, the fenestrated mini-clip was applied in similar fashion to avoid kinking of the ATA instead of a standard clip, thereby preserving the ATA without further aneurysm dissection. Finally, successful obliteration of the aneurysm and preservation of the ATA were achieved with the subsequent clip application. CONCLUSIONS: In selected cases, application of a narrower bladed fenestrated mini-clip in the restricted space may be useful to preserve tightly adhering branch arteries, as well as efferent arteries.

Cerebral Aneurysm Arising from Variant Posterior Communicating Artery Lying Lateral to Oculomotor Nerve.

BACKGROUND: In most cases, the posterior communicating artery (PCoA) lies medial to the oculomotor nerve. In this report, a rare case of a ruptured cerebral aneurysm arising from a variant PCoA lying lateral to the oculomotor nerve is described. CASE DESCRIPTION: A 41-year-old woman who had a history of surgical clipping of a right PCoA aneurysm 13 years earlier developed a subarachnoid hemorrhage due to a ruptured left true PCoA aneurysm. Three-dimensional computed tomography angiography showed a small saccular aneurysm arising from the PCoA itself. She underwent surgical clipping via a left frontotemporal craniotomy. Interestingly, the PCoA lay lateral to the oculomotor nerve, and the aneurysm dome projected medially and compressed the oculomotor nerve medially. A slightly angled fenestrated miniclip was applied across the PCoA, followed by reconstruction of the PCoA medial wall and simultaneous obliteration of the aneurysm. Complete aneurysm obliteration and good patency of both the PCoA and perforating arteries were confirmed intraoperatively by indocyanine green videoangiography. The patient's postoperative course was uneventful, and the patient was discharged with no neurologic deficits. CONCLUSIONS: Recognizing this anatomic variant is helpful in minimizing the potential complications in microsurgical management around the PCoA and oculomotor nerve. Lateral localization of the P1-2 junction might affect this rare anatomic variant.